Goldkist –Scholarship Application form

Institution: _________________                                                                                 (YEAR      /2005)

Name: _______________________                          

Father‘s Name: ______________________                                                   Paste recent                                                                                                                                                                passport size

Sex: M/F                                  Age: ______ Yrs                                              photograph

Date of Birth: _______________

Address (Resi): __________________________________________________________________________

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Contact Ph (O):______________       Resi:______________                        Email:____________________

Educational Qualifications (from Secondary)

Are you studying further                                  Yes                  No

If Yes Give details

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Extra Ordinary capabilities in any field

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Languages known (tick, if can):

1. English                    1.Read             2.Write             3.Speak

2. Hindi                        1.Read             2.Write             3.Speak

3. ___________          1.Read             2.Write             3.Speak

4. ___________          1.Read             2.Write             3.Speak

Family Background

Do your family has

Black n white TV                      Yes                  No

Color TV                                  Yes                  No

Washing machine                    Yes                  No

Microwave oven                       Yes                  No

Scooter                                    Yes                  No

Car                                          Yes                  No

Telephone                               Yes                  No

Mobile Phone                           Yes                  No

Any Income tax payee              Yes                  No

Justify how you are financially backward

1.______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

Explain to us why u need Study scholarship to study?

1.______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

Why u want to study in computer field

1.______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

Write a paragraph about your ambition in life (compulsory)

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Do you smoke                                                  Yes                   No

Do you drink alcohol                                        Yes                  No

Are you vegetarian/Non vegetarian                 Veg                  Non-Veg

Any major illness in last three years, give details ______________________________________________

Religion                                                           __________________

Does U know driving                                        Yes                  No

Does U have driving license                            Yes                  No

If yes, License No.                               Date of issue                           Place of issue

Do You have passport                                                 Yes                  No

If yes, Passport No.                              Date of issue                           Place of issue

Do you have any immediate commitments (like marriage, Examinations, family problems) which might require frequent absenteeism from Job/Study                Yes                  No

If yes, give details

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Is any of your relative/Friends in Taxation Department                        Yes                  No

If Yes Give Details

Is any of your relative/Friends in Computer companies

If Yes Give Details

Reference (Non relative):

I declare that the information provided is true to the best of my knowledge. I understand that if found incorrect at later stage too, it can lead to cancellation of scholarship,

Dated:                                                                                                                     Signature of Applicant

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 (For OFFICE USE)

Ref No: ____________Date recd:___________         Interview:_________

Date     : ____________Officer            :____________           Sign     : _________   

Remarks:

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